HomeMy WebLinkAbout0017 WHITE'S LANE - Health 17 Whited Lane
Cotuit
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p Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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17 Whites Lane„Cotuit ✓ -�:,i
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Property Address
Jennifer'E. Briggs,
Owner
Owner's Name
information ie
required for every 5 Sheridan Road, Yarmouth MA 02664 3/20/19 v:page. City/Town State Zip Code Date of Inspection
t
Inspection results must be submitted on this form. Inspection forms may not be;altere'd in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
S�
on the computer,
use only the tab Jorge Miguel Chavez
key to move your Name of Inspector
,ursor-do not Speakman Excavating LLC
use the return Company:Name
cey.
15 Speak Way .
Company Address
Harwich MA 02645;
Cityrrown State Zip Code
508-432-5565 8114204
Telephone Number License Number
B. Certification
I certify that I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(31.0 CMR 15000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as-of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal.systems.After conducting this:inspection I have determined
that the system:
1. Passes
2. ❑ Conditionally Passes:
3. ❑ Needs Further Evaluation by the Local Approving_Authority
4. ❑ Fails
Inspector's ignature Date
The;system inspector shall submit a copy of this inspection report to.the Approving Authority(Board
of Health or DEP)within'30 days of completing this inspection. If the system has:a designflow of
10,000 gpd or greater, the inspector and.the system owner shall submit the report to the appropriate
regional office of the DEP;The original form should be sent.to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report.only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system wi11 perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Pagel of 18
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Vol untaryl Assessments
17 Whites Lane; Cotuit .
Property Address
Jennifer E. Briggs
Owner Owner's Name
information is required for every 5 Sheridan Road Yarmouth MA. 02664 3/20/19
page. City/Town State; Zip Code: Date of Inspection.
C. Mspection Summary
Inspection Summary: Complete.1,2, 3, or 5 and all of 4 and 6.
1) System'Passes:
I have not found any,information which indicates that any of the failure criteria described
in 3.10 OR 15.303 or in 310 CMR.15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described.in the"Conditional Pass"section need to be
replaced or repaired: The system, upon completion of the:replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes","no"or"not determined" (Y,.N, ND)for the following statements. if"not.
determined,"please explain.
The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank,failure is imminent.;System will pass
inspection if the existing,tank is replaced with a complying septic tank as approved by the Board of
Health;
*A metal septic tank will pass inspection if it is structurally sound, not leaking ar16 if'a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
[]: Y N 0. ND(Explain below)-
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System Pape 2 of'18
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Gommonweann OT massamusens
Title 5 Official Inspection Form
Subsurface:Sewage Disposal System Form-Not for Voluntary.Assessments
17 Whites Lane, Cotuit
Property Address
Jennifer E. Briggs
Dwner Owner's Name
Information is required for every 5`Sheridan Road,Yarmouth MA 02664 3/20/19
page. Gity/Town State Zip Code Date of Inspection
Co Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of`Board'of Health):
broken pipe(s) are replaced ❑ Y i0 N ❑ ND(Explain below)
obstruction is removed ❑ Y 0 N ❑ ND(Explain below)'
❑ distribution'box is leveled or replaced ❑ Y ❑ N 0 ND(Explain below)
Thesystem required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced El .Y
❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y J❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public'health,-safety.or the environment,
a. System will pass unless.Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is.not functioning in am anner which will protect public health
safety and the environment:
t5msp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal'System•Page 3 of 7S:
I ,
liOmmonweaiin or massacnuseus
Title 5 Official Inspection 'Form
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
17 Whites Lane, Cotuit
Property Address
Jennifer E. Briggs
)caner Owner's Name
,formation o
d for
is revery squire 5 Sheridan Road,.Yarmouth MA. 02664 3/20119
age. City/Town State Zip Code Date of Inspection:
C. Inspection Summary(cont.)
❑ Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy js within 50 feet of a bordering-vegetated wetland or a salt marsh
b. System will fall unless the Board of Health(and Public WaterSupplier, if any)
determines that the system is functioning in a'manner that protects the public:health,
safety and environment:
The system hasa septic tank arid soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to:a surface water supply.
❑ The system has:.a septic tank and SAS`and the SAS.is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS land the SAS is within 50 feet of:a private water
supply well.
El The system has a septictank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and.nitrate nitrogen is equal
to orless than 5:ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form_
c: :Qther
4} System Failure Criteria.Applicable to All Systems
You must'indicate""Yes"or"No"to each of the following for all inspections:
Yes No
Backup of Sewage into facility or°system:component;due to overloaded or
clogged SAS or Cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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%.fXmrnonweaiiin oT massacniuseris
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
„J 17 Whites Lane, Cotuit
Property Address
Jennifer E. Briggs
owner Owner's Name
ne aired for
ie 5 Sheridan Road Yarmouth MA 02664 3120/19
-equired forevery
)age. Cltylfown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
41 System Failure Criteria:Applicable to All Systems: (cone:)
Yes No
Static liquid level in the distribution box above outlet invert due town overloaded
or clogged SAS or cesspool
® Liquid depth in cesspool is less than 6`below invert or available volume is less
than Y2 day flow
E ED Required pumping more.than 4 imes in the last year NOT due to clogged or
obstructed pipe(s), Number of times pumped:
❑ ® Any portion of the SAS, cesspool orprivy is below high ground water elevation.
® Any portion of cesspoof or privy is within 1,00 feet of a surface water supply or
tributary to a surface water supply.
® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
Any portion of a cesspool or privy within 50 feet of`a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water qualityanalysis. [This
system passes if the well water analysis, performed at a,DEP,certified
laboratory,for fecal coliform bacteria'indicates absent and the'presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure.criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow.of 2000 gpd-
10,000 gpd.
The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,`therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary.to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a:
design flow of 10000 gpd to 15000 gpd.
For large systems; you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section.C.4_
Yes: No
0 the system is within 400 feet of a surface drinking water supply
❑ 0 the system is within200 feet of a tributary to a surface drinking,water supply
the system is located in a nitrogen sensitive area (Interim Wellhead. Protection
Area—IWPA)or a,mapped Zone II of a public water supply well
15insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 5 of18
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+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Whites Lane,.Cotuit
Property Address
Jennifer E. Briggs
)wner Owner's Name
iformaequined for every Lion is
squire 5.Sheridan Road, Yarmouth MA 02664 3/20/10
gage. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont;)
If you have answered"yes'to:any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat;under'Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15,304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for_each,of the following for all inspections:
Yes lNo
Pumping information was provided by the owner, occupant,,or Board of Health
❑ 0 Were any of the system:components pumped out:in the previous two weeks?
El N: Has the system received normal flown in the previous two week period?
❑ El Have large volumes,of water been introduced to the system recently or as part of
this inspection?
Were as built.plans,of the system obtained and examined?(If they-were not
available note as N/A)
Was the facility or dwelling;inspected for:signs of sewage back up?
E ❑ Was the site inspected for signs of break out?
Z ❑ Were all system components, excluding the SAS;jocated on Site?
0 ❑ Were the septic tank manholes uncovered,,opened; and the interior of the tank
inspected>for he condition of the baffles ortees„material of construction;
dimensions, depth of liquid, depth of sludge and depth of scum?.
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been.determined.based on;
Existing information; For example,a plan at the Board of Health.
❑ Determined.in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [31`0 CMR 15.302(5)1
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
toommonwealiin or massaunusezzs
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,jJ 17 Whites Lane, Cotuit.
Property Address
Jennifer.E. Briggs
lwner Owner's Name
quir6d foti fo is
every
s 5 Sheridan Road, Yarmouth MA 02664 3/20/19
quire
age. City)Town State Zip Code Date of Inspection.
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design)- 3 Numberof bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110'gpd x#of.bedrooms): 330
Description:
Number of current residents: 0
Does residence have a garbage grinder? 0- Yes 0 No
Does residence have:a water treatment unit? Q Yes 0 No
.If yes, discharges to:
Is laundry on;.a separate sewage system?(Include laundry system inspectionEl Yes 0 No
information in this report:)
Laundry system inspected? D Yes 0 No
Seasonal use?' Q Yes ED No
Water meter readings, if.available(last 2 years usage(gpd)):
Detail:
2617: 44,000
2018:62,000
Sump pump? Yes No
Last date of:occupancy: 12/19+/
Date
t5insp.doc-rev.7/28/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
g Lommonweallin or iviassacnuseus
J Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Whites Lane, Cotuit
Property Address
Jennifer.E. Briggs
)wner Owner's Name
nformequine foe 5 Sheridan Road Yarmouth MA 02664 3/20/19
equired for every
)age. City/Town State Zip Code Date of Inspection
D. System Information (cont.
2. Commercial/Industrial Flow:Conditions
Type of Establishment:
Design flow(basedion.310 CMR 15.203); Gallons per day°(gpd)
Basis of design flow(seats/persons/sq.ft., etc.);
Grease trap present? El Yes E] No
Water treatment unit.present? El Yes E 3 No
If,yes,.discharges to;
Industrial waste holding tank present? ❑ Yes ❑ No
Non sanitary waste discharged to,the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping;Records:
Source of information:
Was system pumped as part of the inspection> ❑; Yes Z 'No
If yes, volume pumped: ganons
t How:was quantity pumped determined? .
Reason for pumping:
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 8 of 1i3
1-.ommonweaiin or massacnuseus
1. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary. Assessments
17 Whites Lane,Cotuit
Property Address
Jennifer E. Briggs
)wrier Owner's Name
fformequire for
5 Sheridan Road',Yarmouth MA 02664 3/20/19
equired for every
)age. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
.4. Type of System:
Septic tank, distribution boxi soil absorption.sysfem
Single cesspool:
❑ Overflow cesspool'
❑ Privy
❑ Shared system (ye.s or;no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract:(to be obtained from system owner) and a copy of latest
inspection of the UA system.by system operator under contract
❑ Tight tank. Attach a copy of the D.EP approval.
[] Other(describe):
Approximate age of all components, date installed (if known),and source of.information:
7/16/90 per 000
Were sewage odors detected when arriving at the site? ❑. Yes 0 No
5. Building Sewer(locate on site plan):
Depth below grade: Under slap.
feet
Material of construction:
cast iron ❑40 PVC other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.)'
Building sewer ingood condition,no sign.of leakage or failure.
t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System:•Page 9 of 18.
vunn111ullwedmil ull lviassacnusens
Title 5 Official Inspection Form
Subsurface SewageDisposal System Form -Not for Voluntary Assessments
17 Whites Lane; Cotuit
Property Address
Jennifer E, Briggs
Owner Owner's Name _
information ie 5 Sheridan Road, Yarmouth required for-every MA 02664
page. City/To wn 3/20/19
State Zip Code Date of Inspection
D. System Information (cont.)
6. ;Septic Tank(locate:onsite plan):
Depth below grade: 31"
feet
Material of construction:
®concrete: ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal,-list age
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500
Sludge depth 31
Distance_from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness 0.,
Distance from top of scum to top of outlet tee or baffle 61,
Distance from bottom of scum to,bottom.of outlet tee or baffle
14"
How were dimensions'.determined? Measure+/
Comments(on pumping recommendations inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.)':
Tank is in good condition, no signs of failure, PVC tee in place
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System.Page 10 of 18
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Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments
17 Whites Lane, Cotuit
Property Address
Jennifer E. Briggs
Owner Owner's Name
nquiredifo ie 5:Sheridan Road Yarmouth MA 02664 3/20/19
�equired for every
)age. i ttyrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan).-
Depth below grade: feet
Material of construction:
❑concrete' ❑ metal ❑fiberglass ❑ polyethylene
❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom.of'outlet tee;or baffle
Date of last pumping:
Date.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank.(tank must be pumped at time of inspection)(locate on site plan):
.Depth belowgrade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
[I Other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 1;1 of 18
t.ommonweann OT massacnusetts
:. Title 5 Official Inspection i=orM
Subsurface>Sewage Disposal System Form-Not for Voluntary Assessments
1.7 Whites Lane, Cotuit
Property Address
Jennifer E._Briggs
)caner Owner's Name
,formation is equired for every 5 Sheridan Road Yarmouth MA 02664 3/20/19
age. City/Town State. Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont)
Alarm present: ❑ Yes ❑ No.
Alarm level: Alarm in working Ord ❑ Yes ❑ No
Date of last pumping; Date
Comments (condition'.of.alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution BOX(if present must be opened)(locate on Site plan):
Depth of liquid level above outlet invert 0,
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage:into or out of box, etc.)::
Dbox is in;good condition, watertight, 1 outlet.
t51nsp.doc•rev,7t2koia Title 5 OHlcial inspection Form:Subsurface;Sewage Disposal System-Page 12 of`16
t;ommonweann or massacnuseus
Title 5 Official Inspection Fora
Subsurface Sewage:Disposal System Form-Not:for Voluntary Assessments
17'Whites Lane,Cotuit
Property Address
Jennifer E. Briggs
)caner Owner's Name
iformation is
e uired for eve 5 Sheridan Road, Yarmouth MA 02664 3/20/19
G ry
i /T n
cage. Cty ow State: ZtpCode Date.ofInspection
D.L System Information (cont.):
10. Pump Chamber(locate on site plan),'
Pumps in working order:. ❑ Yes ❑ No*
Alarms in Lworking order:_: ❑ Yes ❑ No*
Comments(note condition of pump chamber;,condition of pumps and appurtenances, etc.):
`If pumps or alarms are not in working order, system is a conditional pass..
11. Soil;Absorption System(SAS)(locate on site plan,°excavation not required:):
If SAS not located; explain why;
Type'
0 leaching pits number:
„ leaching chambers number: 4
leaching galleries number:. ;
leaching trenches number, length:
❑' _ leaching fields number, dimensions;
overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
15insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface;Sewage Disposal System•Page 13'of 18
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Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Whites Lane, Cotuit
Property Address
Jennifer E. Briggs
Owner
Owners Name
information is
required for every
5 Sheridan Road, Yarmouth MA 02664 3/20/19
page. CitylTown State Zip Code. Date of Inspection
i
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note.condition of soil, signs of hydraulic failure, level of ponding damp soil, condition of
vegetation, etc.):
Chambers in good condition, stone looks clean and damp. No signs of failure
12. Cesspools (cesspool'must be pumped.as part of inspection) (locate on site:plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool _
Materials of construction
Indication:of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs:of'hydraulic failure, level of ponding,:condition of vegetation,
etc.):
w .
t5insp doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
toommonweann oT massacnusetm
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
17 Whites Lane; Cotuit
Property Address
Jennifer E. Briggs
7wner Owner's Name
nformequine tifo is 5 Sheridan Road Yarmouth MA 02664 3/20/19:
�equired for every
)age. City/Town State Zip Code Date of Inspection
D. System Information (coat:)
13. Privy(locate on site plan)-
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of pbnding, condition of vegetation,
etc.):
't5insp.doc•rev.7@6I2018 Title.5 Official Inspection Form'.Subsurface Sewage Disposal System•Pape 15 of 18
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Title 5 Official In pectin. Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
17 Whites Lane, Cofuit
Property Address
Jennifer E. Briggs
wner _
Owner's Name
formation is 5 Sheridan Road, Yarmouth squired for every MA 02664 3/20/19
age. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
14. Sketch Of'Sewage Disposal System:
Provide a view of;the sewage disposal system, including ties4o at least two permanent reference
landmarks or benchmarks.Locate all wells within 100 feet. Locate where public watersupply enters
the building. Check one of the boxes below:
❑ hand sketchin the area below
❑ drawing attached separately
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Sinsp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage 01sposaf system•page_16 of"Is
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j� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
>N
17 Whites Lane, Cotuit
Rroperty Address
J.enniferE. Briggs
)wner
Owner's Name
,formation is
equired for every 5 Sheridan Road,Yarmouth MA 02664 3/20/19
-
age. CityfTown State Zip.Code Date of Inspection
D. System Information (coat.)
15. Site Exam:
Check,Slope
Surface water
Check cellar
Shallow wells
Estimated.depth to high ground water: 3;+ below bottom of leaching
'feet
Please indicate all methods used to determine the high ground water elevation:
❑ 'Obtained from::system':design plans on record.
If checked, date of design plan reviewed: Date
Observed:site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health explain'.
El Checked with local excavators, installers- (attach documentation)
[] Accessed USGS database-explain:
You must describe howyou established the:high ground water elevation:
Hand auger.3'below bottom of leaching no water encounter.
Before filing this Inspection Report, please see Report Completeness Checklist on next page..
t5insp.doc fey,742612018 Ti le 6.official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
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%oommonweatin or tlflassacinusens
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Notfor'Voluntary Assessments
17 Whites Lane, Cotuit
Property Address
Jennifer E. Briggs
Owner Owner's Name
information i e
required for every 5 Sheridan Road Yarmouth MA 02664 3/20/19 page. Cityfrown State Zip Code Date of Inspection;
E. Report Completeness Checklist
Complete all applicable sections of this.form inclusive of:
A. Inspector Information: Complete all fields in this section.
B. Certification:Signed& Dated and 1, 2, 3, or 4 checked
C. Inspection Summary.
1, 2, 3; or 5 c.ompleted'as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
D. System Information:
For 8:;Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on;pg:'l6 or attached
For 15 Explanation.of estimated depth to high groundwater included.
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal Swem-Paoe 18 of le
COMMONWEALTH OF MASSACHUSET ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL EXECUTIVE OFFICE OF ONMENTAL PROTECTION
A m
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION \
Property Add
ress: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner's Name: GREGORY YAHM
Owner's Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Date of Inspection: 4/20/01
EAPR2
Name of Inspector:(please print) SEPTIC IIN GRACI IONS 1company Name:Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 LC
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal he inspecystem at tion wasrperformed based on myttraining and below is
true,accurate and complete as of the time of the inspection.T P systems.al I am a DEP approved system
experience in the proper function and maintenance
Title 5(310 CMRsewage dispos The system
inspector pursuant to Section 15.340
X Passes
_ Conditionally Passes
_ Needs Furth `� valuation by the Local Approving Authority
_ Fails
Date: 4/20/01
Inspector's Signature.:
inspector shall submit copy of this inspection report to the Approving
design flow,ty(Board of H
of 10 000 gpd orlgreat th or Dr,Ehe within
The systemp
30 days of completing this inspecti n. If the system is a shared system or
inspector and the system owner shall submit the report to the appropriate
and theTonal office
authority.ER The original should be
Papproving
sent to the system owner and copies sent to the buyer, if applicable,
Notes and Comments
THE SYSTEM
PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
e at that ons of us
****This report only describes conditions at the time r in the a under the samion and under the e or1different conditions of usee. 's
inspection does not address how the system will perform m the
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound;exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old.is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the�Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of i l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped n&.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this forma
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems`?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
i
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
S
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIALANDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203):.n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1998
Were sewage odors detected when arriving at the site(yes or no): NO
r -
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
BUILDING SEWER(locate on site plan)
Depth below grade:42"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:36"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5' 6" W 5' 8""
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: 0"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING
EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
l_
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
INFULTRATORS leaching chambers, number: 4
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY.DID NOT EXPOSE-NO INSPECTION COVER-
THERE WAS NO AS-BUILT ON FILE WITH BOARD OF HEALTH-
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 WHITES LANE MARSTONS MILLS,MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 WHITES LANE MARSTONS MILLS, MA 02648
Owner: GREGORY YAHM
Date of Inspection: 4/20/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 10+FEET
TOWN OF BARNSTABLE ,V/J/
LOCATION 1�� �� �-a`�O 9=? SEWAGE #
,:LLAGE k6ASSESSOR'S MAP & LOT b1 --G6`L
INSTALLER'S NAME&PHONE NO. G`
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR-OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �foxCUA
AA 31
A a 4yL
knL
c
TOWN OF BARNSTABLE
LOCATION 7 i.V v ° SEWAGE # R- 4 1 3
VU,LAGE ASSESSOR'S MAP & LOT 0.1 002
INSTALLER'S NAME&PHONE NO. 1
SEPTIC TANK CAPACITY Sd U
LEACHING FACILITY: (type) i ALL (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMPTDATE: COMPLIANCE DATE: °7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within.300 feet of leaching facility) Feet
Furnished by x 4
t
0
� 6
A 13L 131 �7
4
/l�/ , c ✓
No. �` l Fee
1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
,PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplicactfon for Mi.5pomf *pgtem Con!aruction Permit
Application for a°Permit to Construct( )Repair(P*-)�,Jpgrade( )Abandon( ) ,�Rcomplete System ❑Individual Components
Location Address or Lot No. Il f. o �es Owner's Name,Address and Tel.No.
Assessor's Map/Parcel . 09
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Awo-c4-0 a sE5 Ow
Lc
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 t-n gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. rCA
Description of Soil A.—a
Nature of Repairs or Alterations(Answer when applicable) STL14
VY" C. c p
,ham 0y— Sb��L_t_l t`((l %J L�no`�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and of to place the system in operation until a Certifi-
cate of Compliance has o
Signed Date 7 -��
Application Approved by f Date T-`/y-
Application Disapproved for the following reasons
Permit No. y Z/ 3 Date Issued
No.—� - y 3 .; Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Vermit
Application for a Permit to Construct( )Repair O,Upgrade( y )Abandon( ) ;sLcomplete System ❑Individual Components
V ,
Location Address or Lot No
r? f, . Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ' ^�/ �f� C � � r 'l
. f
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms_ Lot Size sq. ft. Garbage Grinder( ).
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 Q gallons per day. Calculated daily flow -3,`t ! gallons.
Plan Date Number of sheets. `t Revision Date
Title {
Size of Septic Tank S_ !JD 1 'Type of S.A.S. c,if`r ctP�`
Description of Soil ` & 4a
Nature of Repairs or Alterations•(Answer.when applicable) ST
r 1% c a
(\ IL AAL21NL�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and of to place the system in operation until a Certifi-
cate of Compliance has becalssmeA o -
Signed Date 7/ q— F
Application Approved by Date 7'—Zy— e�
J
Applicat/on Disapproved for the following reasons
- — Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS ���'—i- ►
BARNSTABLE, MASSACHUSETTS Z-I z }
Certificate of (Compliance t
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded
Abandoned( )by CA p F S► -t a t'
G
at 1-7 `ki(A'c T r � j LA o)F r c�1 t�'r j`" has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 'yy. dated 7—/
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date "'1 �l C.=/ Inspector (\
Fee _/
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
'Wi0o5ar *P5tem Construction Vermit
Permission is hereby granted to Construct( )Repair( )Upgrade(`{.Abandon
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this e it.
Date: 2— �y� �! .� Approved by
i
'f.
i -
ffT:,C E: This Form" is
To Be Used For the Repair.of Failed
$e�ptic Systems Only i
f
•
TION 4F SKETCH AND APPLICATION FOR
CERTIFICA ITHOUT
IN
POSAL WORKS CONSTRUCTION PERMIT
x. ENGINEERED PLANS _
i works
v by certify that the application for dispose
I' concerning the
' ocrostnletion pt'rtrtit sighed by me dated
Meets wn of the }
lod w at w .
• fonoroving
criteria: • .
^ keehint fhetlhy I ,
wlihM 100 het of d+e p�P� � r
• �71kre ne Ne wethMds loeeted a °:�'
ovule aysk++t k
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wells vol"tab(eat of the ProPoxd i
Mee MIr Aow MAW dop In We,crew
ProPos�d
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�Jt1 a de Im Aeneas
Ieeehhtg
tMelli�r wm be hx W*Rhin 250 het of any wetlands,the button+of that !
•"
ir7 Mgt ItX will be WOW less then fourteen(14)het above the Maxirmmm adjust `
`t1wev table ebvNien. _� ±
p1etM1!1111Mp1lt�the tbne�s� {
(aeeo�dMt to the Entine"M
►fit 'i
9 Obm vW dtedd Tebk Elevetlen
eewding to Heft olvblon well
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DATIL
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INSTALLER M 1'H To"of BONSTABL6 NUMBER ,#
AIM 1000 IM"mW hwe"o Pena ewtlfleA o Pismo 7
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3- -r33
TOWN OF BARNSTABLE of
LOCATION 17 WLt i�i5 L �r/ SEWAGE # / q - �f I
VILLAGE -- ASSESSOR'S MAP & LOT��?- 0La
INSTALLER'S NAME&PHONE NO. r�� � �
SEPTIC TANK CAPACITY �>d"
LEACHING FACILrN: (type) �I FILL•�� (size) -- -
NO.OF BEDROOMS_
BUILDER OR OWNER d Mt
PERMITDATE: :1 — )!::( -9�� COMPLIANCE DATE: -7
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by